Home health agencies are under more scrutiny when it comes to fraud and improper billings than ever before. In a tougher operational climate with higher pressures and more regulations, home health agencies need to be aware of how to fully comply and avoid the Feds‘ fraud radar.
The Medicare Strike Force recently executed the largest fraudulent billings takedown that included home health agencies yet. More than 300 individuals were arrested for a variety of health care schemes totaling more than $900 million. The crackdown is the latest example of ongoing efforts to combat Medicare, and specifically home health, fraud.
“There is pressure out there,” Dr. Andrew Awoniniyi, RN, ND, CDE, director of research and education at home health software company Axxess, told Home Health Care News. “The bad actors have gotten a lot more attention than all the good. That perception out there drives some of that scrutiny out there for home health.”
And the industry shouldn’t expect things to change anytime soon, as the health care system shifts away from fee-for-service reimbursement models and intensified scrutiny helps shape new requirements to combat fraud.
“There is no doubt that the next few years will probably be just as busy on the regulatory front, but the goal is really to move the system to one that’s focused more on value,” Awoniyi said. “It’s not surprising, but it’s challenging nonetheless.”
While committing health care fraud and filing reimbursement documents improperly are very different, there are a few best practices all agencies should follow.
Of course, to avoid the eye of the Feds, agencies should not commit fraud. However, as the saying goes, a few bad apples can spoil the bunch.
“In terms of staying out of the crosshairs, if you’re a provider who wants to do the right thing, the No. 1 thing you should understand about the way the Justice Department works is that once they hold a company accountable for misconduct, they will start looking at all the other vendors in that market,” Eric Young, attorney with law firm McEldrew Young, told HHCN.
This methodology is exemplified in the Centers for Medicare & Medicaid Services’ (CMS) pre-claim review demonstration, which will be rolled out in five states as early as next month. CMS maintains that the pre-claim pilot aims to prevent fraud by authorizing services earlier, and the five states chosen for the demonstration—Illinois, Florida, Texas, Michigan, and Massachusetts—have some of the highest rates of fraud across the country.
There are also some common practices that a recent report from the Office of Inspector General (OIG) for the Department of Health and Human Services identified as suspicious behavior. The report flagged more than 500 home health care agencies for suspicion from these practices.
Fortunately, there are a few things home health agencies can do make it less likely they will be flagged for fraud. Most importantly—and obviously—is that home health agencies should ensure they have a robust compliance program.
“In my experience, even the most sophisticated companies in home care don’t tend to take compliance as seriously as they should until something bad has happened,” Young said. “It would be foolish not to have a robust, legitimate, operational compliance program. Otherwise, it’s a recipe for disaster.”
Engaging with industry associations as well as keeping up with CMS updates can also help fully understand new requirements. Not having all the proper documents can leave an agency in trouble. Even unintentionally not following documentation requirements can be a big problem.
“The main thing that agencies need to be worried about is reckless disregard,” Des Varady, CEO of non-acute health care consultant group Corridor, told HHCN. “It’s a term that means you’re not paying enough attention or doing enough to comply with the rules. It’s not fraud, but it is prosecutable.”
For agencies that are unsure if they are fully compliant with new requirements, seeking legal counsel can provide some benefit, according to Varady. While a lot of home health agencies might not have the resources to have an attorney review their processes, the investment can provide assurance.
“You ought to be talking to your attorney to make sure you’re doing everything right by the law,” Varady said. “It’s a good thing to be doing, to have someone you trust to bounce things off of. It’s tough to run a home health agency these days.”
As part of a compliance program, home health agencies should consider utilizing technology to their advantage. Not engaging with technology, particularly related to documentation, can leave companies vulnerable and disadvantaged as the health system continues to evolve.
“The feds have rolled out their fraud prevention program, so they are using health IT,” Awoniyi said. “If the feds are using technology, then you better be, as well.”
Utilizing electronic medical records (EMRs) is one way agencies can improve their documentation. Accurate and efficient documentation can improve workflow and even reduce vulnerabilities when it comes to submitting claims.
“Documentation is a top vulnerability agencies have, which relates to getting reimbursed,” Varady said.
Agencies need to ensure that compliance processes are communicated well to all staff members, and that the message comes from the leadership, all the experts agree.
“Everything starts with leadership,” Awoniyi said. “Owners have to understand and devote a number of resources for communicating and sharing with employees. It can be challenging when dealing with thin margins, but like any other organization, the employees can be the greatest asset.”
Leadership needs to not only communicate compliance processes clearly with all agency staff, but executives also need to listen to their staff when it comes to fraud. In some cases, according to Young, whistleblowers alert leadership to an issue, but that is ignored, not taken seriously or even retaliated against. Instead, agencies should take time to investigate internal allegations.
“The [fraud] cases that you read about are usually people that had worked for a company for some period of time, were uncomfortable with something that they saw, and they reported it,” Young said. “Listen to whistleblowers or internal reports from people who complain about things. Companies should take it seriously, investigate it and not retaliate against the messenger. The worst thing that could happen is that you listen to someone and they are wrong.”
Above all, home health care agencies should pay attention to their compliance duties and even recognize ongoing shifts offer also greater opportunities.
“We need to continue to reinforce a message of hope,” Awoniyi said. “To remind everyone that there are opportunities that will only continue to grow with learning how to navigate the payment agencies.”
Written by Amy Baxter